Reflections on therapists; Reflections to clients

05Feb

Today I’m writing in response to something I read on another blog that hit home in several different ways for me. It’s not the first time I’ve heard something similar, and while I wish things were different, it won’t be the last. At the same time, I can put myself on the other side of the situation. The issue was between a client and a therapist, and while I don’t think I can put myself into the other therapist’s shoes, I can definitely put myself into the seat next to her in a classroom or at a seminar.

Rephrasing this in my own words, the issue involved the therapist telling the client that she might feel less stress if she didn’t make herself do so much so often. While I believe the therapist meant well and certainly had a point that people are often stressed by doing more than they can or want to do, the client was understandably upset by this. The stressful things she makes herself do involve caring for her children, taking care of herself, managing household chores, and similar issues. The therapist followed this up with telling the client she is very self-aware, very good at using coping skills, and that she, the therapist, can’t really do anything else for the client, so she will stop seeing her.

The client writes that she felt rejected, that she was already having problems with depression (hence seeing a therapist) and that the rejection didn’t help, and that she really wonders if life just doesn’t ever get better – that she will always feel too tired, too sad, to stressed.

Reading this reminded me of two other instances. One happened in the town I now live in, where someone told me that the local county mental health clinic basically looks at people’s ability to meet day-to-day needs, and does not push farther. They want clients in and out in 8 sessions, ideally, and do not want to take the time if a client comes in asking for help to look at past baggage that they have been carrying for years. The attitude is ‘you’re functional. Leave it alone’.

The second instance happened to me several years ago. I was seeing a therapist who professed to work with some of the issues I wanted to deal with at that time. Within a few weeks of seeing her she told me that I acted very differently from most people she’s treated with the same issues. This was a neutral statement, and she wasn’t either willing or able to explain it further, so we went on. After a few months she was very upset by some of the things I told her. She wasn’t upset on my behalf; she was upset that I had talked to my then fiancée instead of talking first to her. At the time, my fiancée had been accompanying me to sessions when he could so that we could talk about how things that affected me affected him, and vice-versa. She told me that she would no longer see me if he was present. That sent up a red flag to me, and I pushed the issue. Although she wouldn’t say so in so many words, she essentially felt either threatened that I trusted him more than her, or she felt that he was a bad influence on me (how?? I don’t know), but she wasn’t willing to say either of these things directly. Instead, she said she could no longer work with me.

I felt incredibly hurt. I felt rejected. I felt like I couldn’t even have a problem in the right way! When I hear these stories, I hear an echo of the same feelings. They are part of the reason I decided to become a counselor – so that I could be the kind of counselor I wanted to have.

Because I am a counselor, and have been through lots of school and continue to attend seminars and conferences and such, I have to take a moment and step to the other side of the situation. In classes about working with clients, therapists are told that when they are not able to continue to help a client, they need to stop seeing that client. They may need to refer the client to someone else. They may need to tell the client specific things they believe the client needs to do in order to continue therapy. There are so many reasons that a counselor could feel unequipped to help or that they are not meeting the client’s needs, but a counselor who is not helping the client does need to stop seeing the client.

This is not just a suggestion. In most places it is a law, and it is certainly an ethical rule. It stems from the need to protect clients. It is unethical to keep inventing issues for a client to work on just to keep the client coming to therapy, and paying the fee. It is unethical to try to help a client with a difficult issue that the counselor feels unequipped to work with. It is sometimes important to nudge people to try their wings, to rely on their own skills. As counselors, we have these considerations repeated over and over, and good counselors keep them in mind.

Going a step further, counselors are human, too. Counselors feel worried, nervous, and out of their depth sometimes. They do have times where they need to put self-care first.

However.

However, there are times where counselors are not truly seeing the needs of their clients. In school, I noticed that most of my classmates spoke a language of relative wellness and safety. They did not speak the language of trauma. They did not automatically check doors and windows to know where to escape if necessary. They did not have a small voice in the back of their head that suggested that someone in charge, like a professor, could do very painful or demeaning things to them if they did not behave correctly. They did not consider inside or outside, tiny halls or large auditoriums, people with a certain hair or skin colour, facial hair or lack of facial hair, a certain pitch of voice or accent to be a potential threat or to raise the heart rate just by existing.

When we talked about things like trust, emotional safety, or ability to speak about difficult issues, I knew that many of the people I sat next to were imagining a very different scenario than I was. As just one example: When we had guests to speak to a class about trauma, it seemed that some of my classmates had not given a thought to ideas like whether a veteran would want to be able to see out a window or request a tour of the building with emphasis on exits before being comfortable to speak to the class.

With that in mind, I am addressing this primarily to my fellow counselors.

When you meet with a client who has been abused, or has anxiety, or depression, or has been through a very traumatic situation, especially an ongoing one, you are meeting with someone who comes from a different place than you are at. You look around your office noticing a comfortable place to sit, your diplomas and certifications speaking of your credentials, your sincere tone and calm demeanor; and you think you see safety and reliability. Your client looks around to see how many doors and windows are there. Most likely, she wants to be able to escape through all of them if necessary, but doesn’t want anyone to be able to look in. She considers the furniture. Can it be thrown? Used as a barricade? Do you have anything hiding behind it? She thinks about how you talk to her. Are you really hearing the fear? The pain? Can you understand it if you do?

You’ve been trained in a variety of tests and tools and routines. You can diagnose if he’s suicidal, eating disordered, depressed, fearful. You have a strong sense of ‘normal’, and you see your client through that lens. It’s normal to have enough energy to wake up, care for kids, make and eat breakfast, get dressed. It’s normal to feel sleepy, to forget something you were supposed to bring along or to take an hour to feel fully awake. Your client speaks of the fatigue of getting ready for the day, of the scramble to get self and/or family ready, to get going, and you think you’ve experienced what he expresses.

You don’t know. Your client is not talking about needing an extra cup of coffee, your client is talking about sincerely wondering if anything today is actually worth getting up. Your client talks about feeling forgetful, strained, bogged down. You think of the notebook resting on the table at home instead of being at work. You think of hunting down a child’s shoe, of not being sure what to make for dinner tonight, of having to fit in a meeting after work.

Your client is talking about wondering if they actually plugged in the coffee maker, or if it was an iron. Or maybe they touched nothing at all. Your client noticed today that their child’s shoes are different from the ones they remember, and would like to ask you if that kind of memory loss is normal.

Your client jokes that she might get more out of therapy today if she just napped for the hour on your couch. You don’t know she’s perfectly serious.

Before you ask, your client is perfectly normal, in her world, his world, my world. Your client is not demented or schizophrenic or delusional. Your client is trying to cope with an enormous amount of stress and fear and pain and frustration; and every tiny thing that goes wrong adds to that load.

For a checkpoint, think about the last time you were very, very tired. Too tired to remember that if you saved the outline of your paper onto a thumb drive, it’s likely still on the computer you were working on if you can’t find the thumb drive. Tired enough that you caught yourself waking up here and there from micro-naps. Think about the last time you felt like everything in the world was riding on one, difficult maneuver that you didn’t think you had control over. Maybe it was a test to be licensed, or to be accepted into school. Maybe it was a tricky place in a relationship. Think about that.

Think about the last time you were emotionally very hurt; a fight, a death, a major disappointment. The last time you didn’t think that anything could really make you happy again.

If you can, think about all these feelings – tired, stressed, anxious, and sad – all rolled into one. Think about how futile everything seemed. Think about how difficult it was to remember to eat – or how eating was the only think that made you feel connected to the world for a minute. Think about how you seemed constantly tired but sleep just made you think things you didn’t like, or made you toss and turn. Think about the feeling that a huge rock was balanced above you, and you had so little control over when it would fall or what it would hit on the way down.

Now: remember that most likely, this was not a usual feeling for you. You felt happy and calm and productive before it, you had an idea that you would feel good and centered and meaningful after you got through it. Think about the ideas you had – that you could always become a truck driver or a guitarist if school didn’t work out, that is the sadness never lifted you’d channel it into art or poetry. Think of the little things – a massage, a walk, a song that you found for yourself, and gave yourself, to remind you to get through.

And think of how much it helped if someone was with you, not making you do anything, but just experiencing the same thing, offering an ear or a hug or being willing to make that trip to the store so you didn’t have to.

Your client doesn’t have many of those last things. Your client doesn’t remember when it felt better. Your client doesn’t have the idea that dreams can come true; or if one dream falls through, it’s a shot at realizing another. Your client may not quite, actually, feel real.

Your client is still not crazy, still not hallucinating, still not schizotypic or autistic or, worst, exaggerating or making it all up.

Your client has not learned HOW to be happy, safe, comfortable, fitting. Many of us, even counselors, think that being happy, feeling safe, fitting in is simply something that happens. It isn’t. It’s something we learn IF we have happy role models, a safe place to grow up, people who accept and encourage us. If we don’t have those factors, we don’t learn those lessons.

Forget, for a moment, the details of the abuse, the level of depression or anxiety on your handy test, their current estimated level of functioning. Just think about leaning, for a moment.

Learning starts at the moment you become aware. Learning starts as soon as you can see or hear or taste or touch or smell or feel or think. Learning starts as soon as you start to be.

Someone who has not been shown much happiness doesn’t learn to recognize it, to feel it, to know it.

Someone who has not had stability does not learn how to make plans and count on them.

Someone who is punished for exploring starts to retreat. Someone who is told, or shown, or both, that the world is a scary and unreliable place starts to feel anxious. Someone who does not know that it is safe to express becomes depressed.

As a metaphor, consider comfort as a cup of hot cocoa. You could have all the hot cocoa in the world, with whipped cream and marshmallows and candy sticks and cinnamon; and if you had never seen or heard of anything resembling a mug, you would have no idea how to acquire and drink a simple, soothing, comfort of a cup of cocoa.

Your client has no mugs. Your client has not been raised with mugs. Your client is uncertain of stores, because they don’t know how to look for a mug or how to tell if it’s the right kind.

All around them, people are rolling their eyes, pointing out that cocoa is available in so many places. Good cocoa and average cocoa and excellent gourmet cocoa and flavoured cocoa and the kind that’s in a packet and has been left too long – but at least it’s cocoa. And your client not only lacks a mug. Your client lacks the idea of a mug.

Most of the time in school, in supervision, in workshops and books and articles and discussions; we as therapists are learning how to improve our clients’ mugs, or cocoa, or both. We’re helping clients notice the cocoa. We’re helping clients consider the best brand for them, their preferred flavor, whether they like marshmallows or cream or plain. We’re going out on a limb, sometimes, and suggesting they may prefer coffee, or tea. We’re taught to help clients to consider how often they can and should drink cocoa, if they should drink it with others, what that want to do if someone continually takes cocoa from the break room and never brings any in.

And then we have a client with no mug come in, and they’ve been through a LOT of therapy. They’ve been in groups and read books and done their homework. They can prepare cocoa starting with cacao beans, and they have 6 years of notes that they took on the subtle differences in every brand and additive and comparison on cocoa, and how they feel about it all.

But they have no idea how to use a mug.

At this point, my analogy breaks down, because it would be so easy if we could just hand a mug and say ‘you’re cured’. And it is a bit more involved than that… or maybe not. Because they need to learn to select a mug; To tell if a mug is clean or dirty, whole or broken. They need to know if it’s okay to get more than one mug, where to get it. They need to know when it’s okay to share with others or not.

We need to model using a mug, yes. We need to keep on modelling it. We need to let the client talk and talk and talk about the same story of wondering what a mug was, because they need to speak of it.

While we’re at it, we need to model spoons and straws, saucers and cream pitchers. We need to show them how to use hot water, how to heat water. And no, that isn’t all. A lot of therapists figure that they have it pretty well complete after they’ve shown the client what they’re missing and how to use it. We’re specifically told we aren’t supposed to be ‘professional friends’. We aren’t supposed to keep treating clients who can ‘do it on their own’ or who are ‘healthy’ now. We’re not supposed to treat outside of our levels of competence.

Our Clients Need More.

Our clients need someone to sit with them as they practice their skills. Our clients need someone to sit with them as they practice their skills again. Our clients need a place that has come to feel safe, because they do know where the exits are and what’s behind the chair. And they know they aren’t alone. Our clients need to know that it’s not enough for us if they know how to use the tools, and the tools to care for the tools.

It’s not enough until they feel safe, serene, and happy as a standard part of life.

For some people this means working with several different therapists. This can be sequential, or it can be congruent. A client can certainly see one therapist for DBT and one therapist for art therapy and one for life coaching. Other times it means seeing the same therapist for a long time, even when the therapist isn’t really seeing change. You, my colleague, are not seeing change at these times because you ARE the change.

You feel comfortable with yourself. You feel happy when happy things happen. You worry and feel sad, but you aren’t consumed by worry and sadness. You wake up, get dressed, get to work, take care of your family and interests and hobbies without losing your grasp on your rope. Your client is learning how to do this from you. You don’t have to adopt the client or tell them about your life in detail. But every session, you model hope, and you are teaching your client how to get it… as long as you don’t ruin it by telling them that they can’t do it, that they’re wrong, that they should be doing something else, that they’re too damaged, to scared, too hurting.

So… how are you teaching it, and how do you keep it up, and where is the line between pushing your bird to fly and dropping them off a branch unsupported?

No, I can’t tell you exactly where it is for every person. But I can tell you the basics. For one thing, we have mirror neurons. Go look them up, really! They’re awesome and more is being discovered all the time. Mirror neurons fire when someone else does something. When you feel happy, calm, and content – your client’s mirror neurons fire and they feel happy or calm or content. When you do something, someone watching has mirror neurons firing helping their brain understand what it’s like to do that thing. That’s right. You don’t have to be the guru of happiness or the lama of serenity. You have to be you, and your clients’ mirror neurons will fire off their own happiness and calm and learning.

You keep it up by keeping yourself cleaned up from your own mirror neurons hurting you. All along, when your client is feeling tiny bits of hope and health and confidence, modeled and passed on by you; you’re noticing their anxiety, their stress, their fear. Your mirror neurons are starting to wonder if there is a problem, and are trying to bring you down and downer. Self-care is NOT a luxury for therapists; it’s a part of treating your clients. Massage or a long shower or a yoga class or working in your garden or whatever. Anything healthy that makes you feel good and cleans out the negativity is essential, so you can keep reflecting the positive, literally.

You keep it up by telling your clients they can do this. You can and should let some of your feelings show when they share with you. It is terrible when children are abused. It is scary to have awful dreams. It is stressful to be trying to build the life they never had while hanging on to what they’ve got. It’s also possible and doable, and you need to express that, too.

You cannot tell your clients that they are too damaged, too traumatized, too abused; or that they already know enough, that they can do this as well on their couch at home as in your office. If your client is able to make it to your office, they are able to make it through. There are times and places for intensive or inpatient work. I wish more of us had the opportunity to have people reflecting hope and confidence and health at us for hours or days or weeks, instead of one appointment every week or two. But if they were too damaged to make it, they wouldn’t be in your office.

If they’re ready to fly solo, there’s a good chance they’ll know, and they’ll be suggesting it. In fact, a lot of us are so used to our lives that we’re more likely to shy away from committing to working deeper and try to leave anyhow, or we’ll take one tiny bit of relief as an amazing change and assume it doesn’t get any better. It doesn’t matter if they’re self-aware, know all the tools, meditate and journal and draw and use affirmations – in isolation, all of these reflect from the client to the client. That limits change. We’re social creatures. We’re not meant to live in isolation. We’re hopeful creatures who desperately want to feel good, and good enough. If we’re alone, or living with people who don’t feel good, then our mirror neurons aren’t reflecting good, and it’s not nearly as helpful as it is when we experience being with someone who gives positive reflections.

You are not being a professional friend or encouraging a malingerer. You’re acting as a reflection of who they want to be. Therapist, therapist, on the couch, show me how to stop the ouch. Counselor, counselor in the chair; show me how it feels to care.

Really lousy poetry, I’m sorry. I can do better, but it doesn’t follow the theme 😉 Your biggest role is not to do, it’s to be. Your client can get to better. They need someone to walk alongside them on their journey there.

You are doing enough. They are not too damaged. They can feel better – and so can I – and so can you.

3 responses to “Reflections on therapists; Reflections to clients”

Well stated. I see this problem quite a bit and it’s sad. When therapists come from a place of “I am going to treat this symptom or diagnosis” they are missing the total person. The best therapists don’t learn to be the best therapists in school. They are naturally very empathic people. I can’t tell you how many times where I’ve mentioned to my peers that my own therapy has helped me tremendously and they look at me as if to say “why do you need therapy? YOU’RE the therapist.” If any therapist thinks they are above the process and not in it, I would stay away. The process I am referring to is being human and experiencing all the things that come with being human.

Exactly! I hear people say things like ‘I don’t know about Ms. Therapist – she’s IN therapy’, and my response is of COURSE she’s in therapy! She wants to be a healthier person, she wants to be sure she’s not letting any of her issues affect her clients, and do you really think dentists just grab their own set of tools and a good mirror when they get a cavity?